Medical triage.

Koryakovsky L.N., Artemyeva V.F., Khareva N.V.

Territorial Center for Disaster Medicine government agency healthcare "Arkhangelsk Regional Clinical Hospital"

The article discusses the basic concepts and terms associated with the occurrence of emergencies, outlines the basics of medical triage and the actions of personnel when working at the pre-hospital and hospital stages. An option has been proposed for conducting medical triage in the first hours of eliminating the medical and sanitary consequences of “uncomplicated” Emergency with insufficient medical forces and resources. The presented material can be used in the process of training management staff and medical personnel of the disaster medicine service.

A feature of emergency situations (hereinafter referred to as emergencies) with mass casualties of people (accidents, catastrophes, natural disasters, terrorist acts, etc.) is the simultaneous appearance large quantity injured. When large-scale emergencies occur, a situation may arise characterized by a large number irretrievable and sanitary losses among the population, including medical personnel, sanitary and epidemiological problems and losses of medical forces and resources.

Experience in conducting training and exercises in medical institutions has shown an insufficient level of knowledge and skills of medical workers in emergency situations, including organizing and conducting medical triage when a large number of victims arrive. Often triage is not carried out for reasons of ignorance of the methodology for its implementation or due to the existing possibility of immediate evacuation of victims due to the proximity of medical facilities and ease of transportation. The information provided is intended to organize the actions of medical workers in an emergency, when the arrival of additional forces and resources is delayed for several hours.

Emergencies

An emergency is a situation in a certain territory or object that has developed as a result of an accident, catastrophe, natural disaster, dangerous natural phenomenon or other action, epidemic, epizootic, epiphytoty, use modern means defeats that may result or have resulted in human casualties, damage to human health and (or) the environment natural environment, significant material losses and disruption of people's living conditions.

A healthcare emergency is a situation that has developed at a facility, in a zone (district) as a result of an accident, catastrophe, dangerous natural phenomenon, epidemic, epizootic, epiphytotic, characterized by the presence or possibility of a significant number of affected (patients), sharp deterioration living conditions of the population and requires the involvement of the forces and means of the disaster medicine service, health care institutions located outside the emergency site (zone, district) for medical support, as well as special organization of the work of institutions and units involved in eliminating the health consequences of emergency situations.

The following are typical for peacetime emergencies:

The catastrophe occurs suddenly with the formation of massive sanitary losses;

Distance of healthcare facilities from the lesion;

A wide variety of injuries: burns, intoxication, injuries associated with being under collapsed building structures, explosions, drowning, a large number of combined and combined injuries;

Isolation of victims before the start of rescue operations, because organizing emergency response requires a certain amount of time before it begins;

Medical and preventive institutions need special organization of work during emergencies;

Simultaneous hospitalization of all affected people in hospitals is impossible;

Inconsistency of medical support, forces and resources at the disaster site with the number of sanitary losses;

Qualified health care the emergency situation is inaccessible to everyone in need;

Direct experience of sorting in emergency situations has a small number of practicing doctors;

The presence of a special group of the population that does not have any somatic injuries but, nevertheless, is considered a victim, these are people with post-traumatic stress disorders, psychological trauma who have lost loved ones, relatives, friends, property. This contingent needs emergency psychological and psychiatric care.

Medical triage

Medical triage is one of the basic principles of disaster medicine, based on the need to provide medical care to the maximum extent possible. short time Maybe more victims who have a chance to survive. This principle differs from the focus on providing care to isolated victims, which is what civil medicine most often encounters. Given the disproportion that always exists during disasters between the number of people affected, the severity of injuries and the amount of medical forces and resources, simultaneous provision of medical care to all victims is practically impossible.

The famous Russian surgeon N.I. Pirogov first introduced into military field surgery and substantiated the principle of sorting the wounded. He defined the work of a “storage area” - a prototype of a sorting point, and pointed out an important circumstance: “Without stewardship and proper administration, there is no benefit from large number healers, and if there are also few of them, then most of the wounded will be left without help at all.”

Describing the picture of dressing stations overcrowded with the wounded in Sevastopol, N.I. Pirogov wrote: “If the doctor in these cases does not assume main goal first act administratively, and then medically, then he will be completely at a loss and neither his head nor his hands will help." The ingeniously simple principle of "Pirogov" sorting is used in almost all armies of the world. It fully retains its significance not only special period, but is also used in peacetime during emergencies with the immediate mass flow of victims to medical institutions. Medical triage - a method of distributing victims into groups based on the principle of need for homogeneous treatment, preventive and evacuation measures, depending on medical indications and the specific situation, the established volume of assistance and the possibilities of providing it at a given stage.

The purpose of triage is to ensure timely medical care and efficient evacuation for those affected.

Medical triage begins in the prehospital period from the moment first aid is provided at the emergency site and continues outside the affected area. At the hospital stage - upon admission of the affected persons to the reception and triage department medical institution for them to receive the full scope of medical care and treatment until the final outcome.

Sorting is carried out on the basis of an emergency diagnosis of the lesion and the prognosis for the life of the victim. It is a specific, continuous, repeating and successive process in providing victims of all types of medical care. Categories of emergency can change quickly and unexpectedly due to the deterioration of the condition of those affected during evacuation.

Continuity of sorting is based on the obligation to carry it out at all stages medical evacuation, starting from the lesion and ending with the reception and treatment specialized departments of clinics.

Repeatability consists of reassessing the severity of the injury at each subsequent stage of medical evacuation.

The continuity of the method is that triage is carried out taking into account the volume and purpose of the next stage of medical care, be it a hospital department or a higher-level medical institution.

Specificity presupposes that sorting is carried out for each specific affected person individually, taking into account the pathology he or she has.

It is customary to distinguish two types of medical triage:

1. Intrapoint: distribution of affected and sick people into groups depending on the need for treatment preventive measures at this stage of medical evacuation according to the place and order of their implementation (i.e. where, in what order and to what extent assistance will be provided at this stage).

2. Evacuation and transport: involves the separation of the injured and sick in the interests of a clear and timely further evacuation (i.e. in what order, by what type of transport, in what position during transportation by transport and where).

Evacuation principles of medical triage:

" Hand yourself" - evacuation of victims from the source of the lesion to a medical institution, or from an overloaded medical institution to others medical organizations.

" Ot themselves" - evacuation of victims to other hospitals to free up bed capacity, as well as patients undergoing treatment during the repurposing of departments.

Types of evacuation:

“In the direction” - carried out on prehospital stage to the nearest medical facility for medical care;

“As prescribed” - carried out at the hospital stage in a specialized medical institution to provide qualified and specialized medical care.

Pre-hospital triage

Medical triage at the prehospital stage, depending on the location of the emergency, can be carried out as in field conditions, and in nearby buildings suitable for receiving victims. For example, when train accidents occur on railway tracks, medical triage is organized in open areas along the railway track. If an emergency occurs directly at the stations, the premises of the stations can be used to provide assistance to the victims while waiting for additional medical forces and ambulance transport.

Medical staff any level of training and professional competence, the first to arrive at the border of the emergency site, must be able to organize medical triage at the prehospital stage.

The first team to arrive at the scene of the incident becomes responsible and works according to the OBDM principle:

O - overview (quick assessment of the scale of the incident);

B - safety (ensuring the safety of personnel at the scene of the incident);

L - treatment ( emergency help victims with threatening conditions);

D - report ( Feedback with managers);

M - activities (prioritization, emergency assistance, transportation).

Before the arrival of the senior doctor at the emergency site (often a doctor from a special team), the senior medical worker is the emergency medical worker (hereinafter referred to as EMC) or the disaster medicine team who was the first to arrive at the site of the emergency. Approximate algorithm of actions medical worker at the border of the emergency outbreak:

1. Introduce yourself to the head of emergency rescue operations and report your arrival.

2. Assess the situation, type and scale of the emergency, the degree of safety for the work of medical personnel at the scene of the incident; determine the approximate number of victims and the forecast, the need for forces and means, the location of the collection point for the injured and the waiting area for ambulance transport, find out the position and name of the head of emergency rescue operations. Report the information received to your immediate supervisor. In the future, report immediately if the situation changes or at the request of the manager.

3. Determine the location for organizing the sorting site and the access route to it, additional areas for providing medical care to the injured and waiting for the arrival of ambulance transport (collection points for the injured).

4. Organize medical triage of victims:

According to the timing of medical care;

Due to danger to others;

According to the order and nature of evacuation.

5. Organize the provision of medical care to victims in accordance with the triage group.

6. Organize the preparation of victims for evacuation by providing information on existing form(full name, date of birth, registration/residence address, diagnosis, severity, information about relatives, name of hospital base).

Victim Collection Point (VCP) - is deployed at the border of the emergency site; it must have adequate access for rescuers, emergency services, medical personnel and transport.

PSP locations are determined responsible persons administrations and medical workers of the facilities, in their absence - the ambulance doctor who arrived first at the scene of the accident.

At the emergency room, in addition to providing medical care, victims are prepared for transportation (preventing the development of disturbances in the functioning of vital organs).

Considering the scale of the emergency, the number of sanitary losses, the availability of medical forces and equipment, weather conditions, collection points for victims can additionally be deployed in adapted buildings with a sorting area, a dressing room, an isolation room, a collection room for the easily injured for their further evacuation, and, if necessary, a site for partial special processing.

On PSP at the most early dates a central sorting zone must be determined - a sorting site located as close as possible to the source of the disaster (terrorist attack), but free from the dangerous influence of damaging factors.

Triage site (SP) - a section of terrain intended for the placement of arriving injured and sick people and their medical triage; in the summer, during daylight hours, if the weather is favorable, the bulk of the tasks assigned to the receiving and sorting (reception and evacuation) unit can be performed here.

The joint venture has a triage team consisting of a doctor and 1-2 paramedics (nurses). The ideal is to create a triage group according to wartime models: a doctor, two nurses, two registrars.

In this case, it is necessary to strictly observe next rule: Newly arrived injured and sick people should be placed in a separate free row of the sorting area. Placing new arrivals in vacated places leads to the fact that they are “forgotten”, since the triage team believes that the injured who are in this series(sector), have already been sorted.

In addition to the main sorting site, there are determined extra seats(sites) for collecting and finding victims of one triage group until the arrival of additional medical forces and transport.

Sorting algorithm

First, medical personnel carry out selective triage - identifying those affected who are dangerous to others: persons with mental disorders and those affected, requiring special treatment from potent, toxic and radioactive substances. Then those most in need of medical care are identified for life-saving reasons (presence of external bleeding, asphyxia, shock, convulsive condition, pregnant women, children, etc.) At this stage of evacuation, the recommended time for working with one affected person is up to 40 seconds. These patients are immediately provided with assistance by SCM teams. The rest of the stream is divided into “walkers” and “stretchers”. This division makes it possible to avoid disorganization in work, which constantly occurs when there is a massive influx of affected people.

Under equal other conditions, medical care is provided first to children, then to pregnant women.

During selective triage, medical care is not provided to all “walking” victims.

After the selective sorting method, the sorting team proceeds to a sequential (conveyor) inspection of the “stretchers” of the affected people.

Based on the examination, the doctor makes a triage decision, dictates the necessary data to be recorded in the primary medical record, and instructs the nurse (paramedic) to perform the necessary medical events and designation of the triage group for the 1st affected person. Then the doctor with another nurse (paramedic) moves on to the second affected person. Having made a decision on it, the doctor and the nurse (paramedic), who remained with the 1st victim, move on to the 3rd victim, etc.

Rice. 1. Scheme of the conveyor method of work of the sorting team.

The triage doctor must assess the degree of threat to the life of the injured person at the time of triage, the possibility of hidden injuries, the timing possible development subsequently adverse complications and outcomes, then draw the correct conclusion. Sorting is carried out on the basis of external examination data, without removing the bandages and without using labor-intensive research methods.

During an external examination of the victim and his interview, the following is determined:

Localization of injury: head, chest, abdomen, pelvis, limbs, spine;

Nature of injury; mechanical injury- local, multiple, combined, presence of bleeding, bone fractures;

Syndrome of prolonged tissue crushing, burns, poisonous substances, radiation injuries, etc.;

Leading defeat threatening this moment life of the affected person;

Severity of the condition: presence (absence) of consciousness, reaction of the pupils to light, pulse, breathing patterns, presence of convulsions, skin color. Arterial pressure don't measure!

Possibility of independent movement;

The nature of the necessary medical care, the time and place of its provision, the procedure for further evacuation (removal, removal).

Signs of extreme trauma visible from afar :

The most severe injuries were suffered by victims who were in the cabin, next to the deformed part of the car;

When hitting a pedestrian, the greater the distance between the lying pedestrian and the car, the more severe the injury;

Symptom of a “removed shoe” when hitting a pedestrian or a mine-explosive injury - if the victim was “shaken out” of clothes or shoes;

In injured unconscious men with severe traumatic brain injury, an erection occurs - a sign of extremely severe TBI and almost 100% a sign of a close fatal outcome(defeat medulla oblongata- “brain stem”, irritation of its centers);

Dirty and torn clothes, traces of “drag” on the clothes of a lying victim;

Traces of soot on clothes;

Electrical marks - burns at the point of entry into the body of electric current;

Very rapid breathing for a lying victim - more than 40 per minute;

Very rare breathing for a lying victim - less than 6 per minute;

The victim's clothes were heavily soaked in blood; a pool of blood formed under the lying victim.

During triage (no more than 1 minute per patient), basic first aid is provided, preferably limited to:

Ensuring free conduction of the respiratory tract and giving the victim a stable position on his side;

Fig.2. Stable position on your side.

Quickly stop extensive/serious external bleeding;

If possible, cover the victim with a blanket or similar to reduce heat loss;

If possible, appoint a person to monitor changes in the victim's condition.

In accordance with Art. 31-33, 35-36, 41 of the Federal Law Russian Federation dated November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”, in the event of emergency situations, victims can be provided with the following types of assistance:

First aid is provided by employees of the internal affairs bodies of the Russian Federation, military personnel, fire service workers, rescuers and drivers Vehicle, etc.

Primary health care, which includes:

Primary pre-hospital health care provided by medical workers with secondary medical education(paramedics, midwives, etc.),

Primary medical care, which is provided by general practitioners, pediatricians, etc.

Primary specialized care is provided by medical specialists.

Specialized, incl. High-tech, care is provided in a hospital setting.

Ambulance, including specialized emergency medical care - is provided to citizens in case of illnesses, accidents, injuries, poisoning and other conditions requiring urgent medical intervention, in an emergency or emergency form outside a medical organization, as well as in outpatient and inpatient settings.

If an emergency occurs and there is a lack of medical resources and resources, it is impossible to provide assistance according to standards. The amount of assistance will depend on the qualifications of medical workers and the availability of medical equipment.

During triage, victims are assigned a specific triage category (group). After determining the triage group, the porter link transfers (transfers) the victims to additional sites (collection points for the affected) in accordance with the triage group.

Given the panic, chaos, confusion and bustle that occur during disasters, the entire triage system must be simple, clear and consistent throughout all stages of medical evacuation.

In the event of a chemical, radiation, or bacteriological outbreak, a site for special treatment of vehicles and a department for partial/full sanitization of victims are additionally organized. The staff works using personal protective equipment.

Sorting is based on three sorting criteria:

1. danger to others - victims are divided into groups:

Subject to special/sanitary partial or complete treatment;

Subject to temporary isolation (mental disorders).

2. therapeutic sign - according to the degree of need for medical care, groups are distinguished:

Those affected in terminal conditions with trauma incompatible with life, in need of symptomatic care (agoning);

Those in need of emergency medical care first (for health reasons);

Those in need of EMF on a second priority (help may be delayed);

Those in need of outpatient medical care (mildly affected).

3. evacuation sign - those affected are divided into groups:

Those subject to evacuation outside the emergency focus to other specialized medical institutions, taking into account the priority, method of evacuation (lying or sitting), type of transport;

According to the severity of the condition - non-transportable, remain in this medical institution temporarily or until the final outcome;

According to the severity of the condition - mild degree, are subject to treatment and observation in an outpatient setting at the place of residence.

The results of medical triage are recorded using sorting marks, as well as entries in the primary medical card of the affected person and medical history. Sorting marks in the form of colored tapes or paper strips are attached to the clothes of the affected person (patient) in a visible place with pins or special clips.

In the absence of sorting marks, visual identification of victims is used by marking them with color. You can use lipstick, marker, felt-tip pen. The inscription should be placed on a clearly visible place on the victim’s body, most often the forehead. The designations on the stamps serve as the basis for directing the affected (patient) to one or another functional unit and determining the order of its delivery.

Write the letters depending on the severity:

H (black)

K (red)

F (yellow)

G (green)

Sorting the mass number of casualties:

1. Black: death, permanent injury. The black mark can only be used if you are 100% sure and have checked the signs of death. If in doubt, it is better to use a red mark. Upon arrival at the hospital: morgue (dead and deceased during transportation).

2. Red: life-threatening injuries, emergency intervention is necessary to save the lives of the victims. Upon arrival at the hospital: department emergency care(resuscitation).

3. Yellow: Urgent medical attention is required. Close medical supervision is required. The condition may worsen within a few hours. Upon arrival at the hospital: specialized or intensive care unit.

4. Green: The condition is stable at the time of examination and requires minor medical attention or medical observation for a certain period of time. Upon arrival at the hospital: outpatient department (polyclinic).

Rice. 3. Approximate scheme for organizing medical triage at the prehospital stage.

Approximate calculation of the number of SMP teams required to evacuate victims:

Effective minimum:

For 3 victims - 2 SKMP brigades;

For 5 victims - 3 SMC brigades;

Up to 10 victims - for every 5 people, 3 SMC teams;

Up to 50 or more - for every 10 people there are 5 SMC teams.

Desired maximum:

For each victim of the “red” group - one specialized SCM team (resuscitation or intensive care);

For each victim of the “yellow” triage group, there is one medical team from SMC;

For every two or three victims of the “green” triage group, there is one SKMP paramedic team.

Optimal timing of care at the prehospital stage:

First aid - up to 40 minutes, in case of poisoning - up to 10 minutes, if breathing stops, this time is reduced to 5-7 minutes;

Pre-hospital medical care - up to 2 hours;

Primary medical care- up to 6 hours;

Primary specialized assistance- till 12 o'clock.

The importance of the time factor is emphasized by the fact that among those who received first aid within 30 minutes. after an injury, complications occur half as often as in persons who received assistance later than this period.

To ensure continuity of medical care for victims during the evacuation stages, an accompanying coupon is filled out in accordance with Appendix No. 3 of Order No. 112 of the Ministry of Health and Social Development of the Russian Federation dated 02/03/2005 statistical forms disaster medicine services of the Ministry of Health and social development Russian Federation".

Medical triage at the hospital stage

At the hospital stage, those affected are provided with specialized services, incl. high-tech medical care.

A medical organization that has a hospital in its structure is intended to provide all types of medical care and treatment of the affected person until the final outcome. Considering the likelihood of a massive influx of injured people, the medical organization, immediately after receiving information about the emergency (disaster), should carry out preparatory activities, including:

Informing and calling personnel (and not only medical) to strengthen the duty shift;

Discharge of patients to be outpatient treatment, in order to prepare beds to receive the affected;

Deployment of additional beds, repurposing departments in accordance with the predominant nature of the lesions in the outbreak;

Repurposing the reception department into a reception and sorting department (sorting and evacuation);

Replenishment of medicines, dressing material and etc.

All these activities are feasible in a short time only if there are pre-developed plans for working in emergency situations, providing for interaction as structural divisions institution, as well as a specific institution with other medical organizations, various services involved in providing assistance to the affected.

When developing a plan for an institution’s work in emergency situations, it is necessary to take into account the capabilities of a specific medical organization and the forecast of the number of affected people in need of medical care. The most likely options for the operation of a medical institution are:

1. The medical organization is able to provide timely and adequate medical care to all injured persons brought to emergency department from the source of the emergency. The hospital provides admission to the affected people, clarification of the diagnosis (carrying out all necessary diagnostic studies), hospitalization and treatment until final outcome or referral to outpatient treatment.

2. The medical organization cannot provide timely and adequate medical care to all injured persons brought to the emergency department from the source of the emergency. When a significant number of injured people arrive, a medical organization located on the border or near the source of the emergency will be the final stage of medical evacuation only for a small part of the injured. Most those affected will need to be evacuated to other medical facilities after providing them with the minimum possible assistance and preparing for evacuation. In this case, along with triage sites, evacuation sites are deployed to form groups and send victims to the next stage of medical evacuation.

To properly and quickly carry out medical triage at the hospital stage, it is envisaged to deploy a reception and triage department (ATR), taking into account the required area to separate the flow into stretchers and walking patients, which includes:

A distribution post (DP) is created to distribute the flow of affected people (uncontaminated and contaminated with radioactive, chemical, bacterial substances, walking, stretchers, infectious, mental, somatic);

Site for special treatment of vehicles, decontamination and decontamination of uniforms and equipment;

The sanitary treatment department, in which (partial or complete) sanitary treatment of victims is carried out;

Isolators for temporary accommodation of infectious patients and victims with mental disorders;

Diagnostic rooms and laboratory;

Intensive care wards (anti-shock, dressing rooms, etc.) and wards for temporary hospitalization.

Rice. 4. Approximate scheme of medical triage of victims at the hospital stage.

Upon admission of affected and sick people in need of sanitization due to contamination with radioactive substances, chemical agents, and biological substances, the sanitary checkpoint first carries out the treatment of this group before sorting, and then proceeds to the hygienic washing of all other affected and sick people. In cases where such a group of affected people does not arrive, the sanitary checkpoint carries out hygienic washing of all affected and sick people after medical triage. Affected people in need of emergency medical care without sanitary treatment are admitted to the appropriate functional departments.

From the PSO, the victims are admitted to the specialized departments of the hospital (surgical dressing rooms, anti-shock departments, resuscitation and intensive care departments, etc.);

To ensure uninterrupted operation of the PSO, auxiliary units are involved: pharmacy, medical equipment warehouse, sterilization rooms, business units (laundry, catering unit, staff quarters), etc.

Rice. 5. Approximate diagram of the deployment of the reception and sorting department.

Composition of sorting teams

To create them, it is necessary to allocate the required number of medical personnel:

1. Doctor - 1, nurses - 2, receptionists - 2 (sorting “stretcher” victims).

2. Doctor - 1, nurse- 1, registrar - 1 (sorting of “walking” victims).

The capacity of 1 triage team is 20-25 casualties per hour. Teams must be provided with appropriate instruments, apparatus, means of recording sorting results, etc. Sorting teams are created primarily by the staff of the reception department, with the involvement, if necessary, of the most trained specialists from other departments.

When performing triage, 4 streams of affected people are distinguished:

FIRST STREAM - infectious patients and patients with psychomotor agitation are subject to referral to the appropriate isolation wards;

SECOND STREAM - is sent to the receiving and sorting department (site) with the release of:

- “stretcher” affected: severely affected with rapidly increasing, life-threatening injuries; affected by OV with the threat of loss of function of one or more major life-support systems. To eliminate violations, urgent treatment is necessary. Those affected by this triage group need help for urgent life reasons (including surgery). Temporarily non-transportable, evacuation to other hospitals is possible only after stabilization of hemodynamics, breathing, and central nervous system activity. Depending on the nature of the injury, they are sent to the anti-shock, intensive care, dressing, operating rooms, etc. to receive emergency care;

- “walking” victims: those affected with severe and moderate injuries that do not pose an immediate threat to life. The prognosis is relatively favorable. Medical care is provided as a second priority or may be delayed for several hours (however, the possibility of severe complications cannot be excluded);

The THIRD STREAM is sent to the evacuation zone for further evacuation. The prognosis for life is favorable. Development dangerous complications unlikely. They need outpatient treatment at their place of residence. The general condition of such patients is satisfactory. There are practically no hemodynamic and respiratory disorders;

FOURTH STREAM - agonizing (dead). The prognosis is unfavorable. Those affected in this group need symptomatic treatment, in alleviating suffering. They are not subject to evacuation.

Conclusion

Medical triage is one of the most important organizational methods aimed at the successful implementation of a two-stage system of treating the population in emergency situations. Properly organized sorting contributes to the rational use of forces and resources medical service for timely and complete provision of all types of medical care to victims, their treatment and evacuation. At present, a single mechanism has not yet been developed by which it is possible to accurately and accurately distribute those affected into categories. Each area of ​​medicine is trying to choose its own method that approximately meets the criteria for reducing mortality in the event of a mass influx of affected people.

It is impossible to strictly adhere to any one sorting system in all situations; each of them can be supplemented by successful various techniques taken from other systems. Here the cardinal role is played clinical assessment, experience of medical personnel. Preparation and planning for emergencies are very important for successfully dealing with their consequences. To do this, medical personnel must constantly improve their knowledge, skills and abilities, as well as be informed about the resources that can be used in eliminating the health consequences of emergencies.

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Medical triage represents the distribution of the wounded and sick into groups based on the need for certain homogeneous treatment, evacuation and preventive measures in accordance with medical indications and the volume of medical care that can be provided at this stage of medical evacuation in specific conditions of the situation.

Medical triage is the most important event, ensuring a clear organization of the work of the stages of medical evacuation to provide medical care. Its role especially increases with the mass arrival of affected people. Sorting was first used by N.I. Pirogov in the dressing detachment in March 1855.

Purpose of medical triage– ensure the fastest provision of medical care maximum number the wounded and sick who need it. Medical triage is carried out on the basis of determining the diagnosis of an injury or disease and its prognosis, and therefore is diagnostic and prognostic in nature. The most important people should participate in its implementation experienced doctors. It is advisable to carry out medical triage by triage teams consisting of a doctor, two nurses (paramedics), and two registrars. As a rule, the sorting team is assigned a link of orderlies-porters. One triage team can triage 15-20 affected people within an hour of work.

Based on the methods of organizing (carrying out) medical triage, it can be divided into:

B) Transitional (transport)– when a large number of people affected come from sources of mass sanitary losses and when there is any threat of EME. It is carried out directly on the evacuation transport, the doctor climbs on board the vehicle, selects the wounded who need emergency care at this stage, who are unloaded from the vehicles and left at the EME. And the rest of the wounded are sent in transit to the next EME.

IN) Selective- This First stage triage using the standard “roll over” technique, where the triage team first identifies and works with the most seriously injured in the triage area, those in need of urgent measures medical care.

Depending on the tasks being solved, there are two types of medical triage: intra-point and evacuation-transport.

Intra-point sorting is carried out with the aim of dividing the wounded and sick into groups for referral to the appropriate functional units of a given stage of medical evacuation and establishing the order of their referral to these units.

Intra-point and evacuation-transport sorting are often carried out simultaneously, i.e. along with identifying the flow of wounded and sick people who need certain medical care at this stage, the evacuation purpose, sequence, method and means of evacuating the wounded and sick who do not need medical care at this stage are determined. The provision of assistance at this stage ends with evacuation and transport triage.

The main groups of casualties identified as a result of triage at the stage of medical evacuation:

1. Posing a danger to others(infectious patients, patients in a state of psychomotor agitation, infected with BS, having contamination skin and uniforms of chemical agents and radioactive substances with a dose rate measurement exceeding the permissible ones), and, therefore, subject to sanitary treatment or isolation.

Subsequently, from the isolation ward, patients go for evacuation in a separate stream, and from the special treatment department to the reception and triage department and the medical care department.

Those who do not pose a danger to others go from the distribution post to the reception and sorting department.

2. Those in need of medical assistance at this stage; go from the reception and triage department to the medical care department, then to evacuation or to the hospital department, after which either evacuation or return to production is possible.

3. Subject to further evacuation and not requiring medical assistance at this stage; are leaving the reception and sorting department for evacuation.

4. Suffered injuries incompatible with life and those in need of care only (agoning).

This group is identified conditionally, a place for such patients is selected separately, and in the future, despite their injuries, they will be evacuated for subsequent EME. In all cases, we must maintain a humane attitude towards the wounded and take all measures to save the lives of as many of the wounded as possible.

5. To be returned to production(after appropriate medical care and short rest).

The results of medical triage are recorded using sorting marks, as well as by recording in the primary medical card(f.100). Sorting marks are attached to the victim’s clothing in a visible place with pins or special clips. The designation on the stamp serves as the basis for sending the affected person to one or another functional unit and determining the priority of delivery.

For each type of disaster in peacetime and war, the size and structure of sanitary losses among the population are very diverse and difficult to predict based on the place and time of their occurrence. High specific gravity in their structure, severe, especially multiple and combined lesions will cause frequent mortality among those affected if medical care is not provided to them in a timely manner. Approximately every third or fourth person affected requires emergency medical care. According to the World Health Organization (WHO), 20% of those killed in peacetime accidents could have been saved if medical assistance had been provided to them at the scene of the accident.

In case of immediate occurrence mass casualties among the population and the lack of medical forces and resources, it is impossible to provide timely assistance to all those affected. It will be necessary to establish a priority in providing medical care to the injured and their evacuation. Make a choice. And if the medical worker does this late, then this problem will be solved by the most in a cruel way nature itself. For such situations, N.I. Pirogov, more than 140 years ago, proposed a special method (method) for organizing the provision of medical care to the wounded, which he called Medical Triage. This method is as follows. “Here, desperate and hopeless cases are first highlighted... and they immediately move on to the wounded, who show hope for a cure, and all attention is focused on them. The principle of medical triage is the choice of the lesser of two evils” 1. During the triage process, he recommended dividing the wounded into 5 groups depending on the severity of the injury, their need for assistance and evacuation. His provisions on medical triage still remain the basis of modern theory and practice of organizing the provision of medical care to the affected.

Medical triage is a method of distributing those affected into groups based on the principle of need for homogeneous treatment, preventive and evacuation measures, depending on medical indications and specific conditions of the situation. It is one of the most important methods of organizing the provision of medical care to those affected in case of mass outbreaks.

The purpose of triage, its main purpose, and service function is to ensure that those affected receive timely medical care in the optimal volume and rational evacuation.

Timely assistance provided is assistance that saves the victim’s life and prevents the development of dangerous complications. Therefore, the main actions of a medical worker should be aimed at providing the correct timely benefits for medical reasons, taking into account the conditions of the emergency situation. At its core, medical triage is deeply humane and is one of the manifestations of mercy and spirituality. The success of medical care in natural disasters, disasters is directly dependent on the correctness and timeliness of medical triage.

Medical triage is a specific, continuous process of organizing all types of care. It should begin directly at the collection points of the affected, at the stages of medical evacuation.

Types of sorting. Depending on the tasks to be solved at the stages of medical evacuation, it is customary to distinguish two types of medical triage: intra-point and evacuation-transport.

Intra-point sorting is carried out with the aim of distributing the injured into groups depending on the degree of their danger to others, the nature and severity of the injury, in order to make an adequate decision on providing assistance to the injured.

Evacuation and transport sorting is carried out with the aim of distributing those affected into homogeneous groups according to the order of evacuation, type of transport, and determining the destination - evacuation destination.

These issues are resolved during the triage process based on the diagnosis and prognosis of the patient’s condition. “Without a diagnosis,” writes N.I. Pirogov, “correct sorting of the wounded is unthinkable” 1 .

Basic sorting characteristics. At the basis of sorting, the three main Pirogov sorting criteria still retain their effectiveness:

a) danger to others,

b) medicinal,

c) evacuation.

The danger to others determines the degree to which those affected need sanitary or special treatment or isolation. Depending on this, those affected are divided into groups:

Those in need of special (sanitary) treatment (partial or complete);

Subject to temporary isolation (in an infectious disease or psychoneurological isolation ward);

Not requiring special (sanitary) treatment.

Therapeutic sign is the degree of need of victims for medical care, the priority and place (medical unit) of its provision.

According to the degree of need for medical care in the relevant units of the evacuation stage, those affected are distinguished:

Those in need of emergency medical care;

Not in need of medical care (care may be delayed);

Those affected with trauma incompatible with life, in need of symptomatic assistance to alleviate suffering.

Evacuation sign - the need, the order of evacuation, the type of transport and the position of the affected person on the transport. Based on this sign, those affected are divided into groups:

Those subject to evacuation outside the outbreak (affected area), to other territorial, regional medical institutions or centers of the country, taking into account the evacuation purpose, priority, method of evacuation (lying, sitting), type of transport;

Those subject to leaving in this medical institution (due to the severity of the condition, non-transportable) temporarily or until the final outcome;

Subject to return to place of residence (resettlement) or short-term delay at the medical stage for medical observation.

Particular attention is paid to identifying victims who are dangerous to others and in need of emergency medical care.

Average participation range medical staff in carrying out medical triage is very wide, depending on the position he occupies in the medical service system (emergency team first aid, medical and nursing teams, triage medical teams, auxiliary triage bodies - RP, VRP, etc.). Depending on this, the paramedic and nurse must be able to work not only as part of these specified units and institutions, but also outside of them, when they have to make independent triage decisions in the absence of a doctor.

Depending on the tasks being solved, it is advisable to distinguish two methods of medical triage:

Intrapoint;

Evacuation and transport.

Intra-point sorting victims at the stages of medical evacuation is carried out with the aim of distributing them into groups depending on the degree of danger to others, the nature and severity of the injury - to establish the need for medical care and its priority, as well as to determine the functional unit (medical institution) of the medical evacuation stage where it should be be provided.

Evacuation and transport sorting carried out for the purpose of:

Distribution of those affected into homogeneous groups according to the order of evacuation, by type of transport (road, aviation, railway);

Determining the location of the injured on means of evacuation (lying, sitting; on the first, second, third tier);

Definition of the destination - evacuation destination.

The following are taken into account: the condition and severity of the affected person; localization, nature, severity of injury. These issues are resolved based on diagnosis, prognosis and outcome. Without them, correct sorting is unthinkable.

Distinguishing other types of triage, for example, prognostic or based on the time of its implementation ("primary, secondary, final") or the qualifications of the medical staff conducting the triage ("pre-hospital, medical", etc.), is unlawful. This does not meet the goals and objectives of sorting. Medical staff of any level of training and qualifications are obliged to provide medical care first of all to those who need it most, if there is a need for choice (for example, when several seriously injured patients are admitted at the same time). In a complex situation of mass disaster, unlike normal conditions healthcare, a particularly bitter moment from a moral and ethical point of view in the actions of a doctor is the cruel necessity of choice.

2. Basic sorting characteristics.

At the heart of sorting, three main sorting criteria still retain their effectiveness:

a) danger to others;

b) medicinal sign;

c) evacuation sign.

Danger to others determines the degree of need of victims for sanitary or special treatment, isolation.

Depending on this, the victims are divided into groups:

1. Those in need of special sanitary treatment (partial or complete).

2. Subject to temporary isolation.

3. Not requiring special (sanitary treatment).

Curative sign- the degree of need of victims for medical care, the priority and place (medical unit) of its provision.

According to the degree of need for medical care, those affected are distinguished:

Those in need of emergency medical care;

Not in need of emergency medical care (care may be delayed);

Those affected in terminal conditions, in need of symptomatic care, with injury incompatible with life.

Evacuation sign- necessity, order of evacuation, type of transport and position of the injured person on transport.

Based on this, the affected people are divided into groups:

Those subject to evacuation to other territorial, regional medical institutions or centers of the country, taking into account the evacuation purpose, priority, method of evacuation (lying, sitting), type of transport;

Those subject to stay in this medical institution (depending on the severity of the condition) temporarily or until the final outcome;

Those subject to return to the place of residence (resettlement) of the population for outpatient treatment or medical observation.

Particular attention is paid to identifying victims who are dangerous to others and in need of urgent medical care.

Carrying out medical triage is most effective when creating triage teams, which include sufficiently experienced doctors of the relevant specialty who are able to quickly assess the condition of the victim, determine the diagnosis (leading lesion) and prognosis, without removing the bandage and without using labor-intensive research methods, and establish the nature of the necessary medical care and evacuation procedures. To do this, if possible, given the fluctuating nature of the arrival of the affected, medical personnel from other departments (during the period of their deployment, etc.) and even from other hospitals (emergency medical teams, etc.) are temporarily involved.

Optimal composition of the medical triage team:

- for stretchers when providing first medical and qualified medical care: a doctor, a paramedic (nurse), a nurse, 2 registrars and a line of porters;

- for walkers affected, a triage team is created consisting of a doctor, a nurse and a registrar.

Medical personnel of any level of training and professional competence (sanitary squad, nurse, paramedic, doctor) must first perform selective sorting, identify those affected who are dangerous to others. Then, through a quick review of those affected, identify those most in need of medical care (presence of external bleeding, asphyxia, convulsive condition, women in labor, children, etc.). Priority remains for those in need of emergency medical care.

After sampling method triage medical staff proceeds to “conveyor” (sequential) inspection affected.

With this “conveyor” sorting method, one sorting team can sort up to 30-40 stretchers of traumatological patients or those affected by hazardous chemicals (with emergency care) in 1 hour of work.

Upon external examination of the victim and his interview, the following are determined:

Localization of injury: head, chest, abdomen, pelvis, limbs, spine;

Nature of injury: mechanical injury - local, multiple, combined (severity of injury), presence of bleeding, bone fractures, prolonged compression of tissues; burn injury - damage by combustion products, hazardous chemicals, radiation damage, etc.;

A leading lesion that currently threatens the life of the affected person;

Severity of the condition: presence (absence) of consciousness, forms of disturbance of consciousness - confusion, stupor or coma; reaction of pupils to light; pulse; breathing features; presence of bleeding, convulsions; blood pressure level (according to indications), changes in complexion and skin;

Opportunities for independent movement, etc.;

The nature of the necessary medical care, the time and place of its provision (ambulance team, medical and nursing teams, medical teams, units of a medical institution) or the procedure for further evacuation (removal, removal).

As a result of the information received, a diagnosis and prognosis of the injury is established, the degree of threat to the life of the injured person at the time of triage, the urgency, priority of provision and type of medical care at the moment and at the subsequent stage of evacuation, the need to establish for the injured person special conditions placement (isolation from others, etc.) and the procedure for further evacuation.

Medical triage.

The principle of medical triage is the choice of the lesser of two evils."

In emergency situations, there is always a discrepancy between the need for medical care and the ability to provide it. Medical triage is one of the means to achieve timely provision of medical care to victims.

MEDICAL SORTING is a method of distributing victims into groups based on the principle of need for homogeneous treatment, preventive and evacuation measures, depending on medical indications and specific conditions of the situation. It is carried out starting from the moment of provision of first medical aid at the site (in the zone) of an emergency and in the pre-hospital period outside the affected area, as well as upon admission of those affected to medical institutions to receive the full scope of medical care and treatment until the final outcome. Medical triage is based on diagnosis and prognosis. It determines the volume and type of medical care.

Medical triage is a specific, continuous (emergency categories can change quickly), repetitive and consistent process in providing victims of all types of medical care. It is carried out on the basis of diagnosis and prognosis. It determines the volume and type of medical care.

At the source of the lesion, at the site where the injury occurred, the simplest elements of medical triage are performed in the interests of providing first aid. help. As medical personnel (ambulance teams, medical and nursing teams, emergency medical teams) arrive in the disaster area, triage continues, becomes more specific and deepens.

The specific grouping of those affected during medical triage varies depending on the type and volume of medical care provided. The volume of honey assistance, in turn, is determined not only by medical indications and the qualifications of medical personnel, but, mainly, by the conditions of the situation.

Depending on the tasks solved during the sorting process, it is customary to distinguish two types of honey. sorting:

¨ intra-point: distribution of those affected by units of a given stage of medical evacuation (i.e. where, in what queue and to what extent assistance will be provided at this stage)

¨ evacuation and transport: distribution by evacuation purpose, means, methods and order of further evacuation (i.e. in what order, by what transport, in what position and where).

The basis of sorting still retains its effectiveness three main Pirogov sorting criteria:

1. danger to others

2. medicinal

3. evacuation

The danger to others determines the degree to which victims need sanitary or special treatment or isolation. Depending on this, the victims are divided into groups:

· requiring special (sanitary) treatment (partial or complete)

subject to temporary isolation

· not requiring special (sanitary) treatment.

Therapeutic sign is the degree of need of victims for medical care, the priority and place (medical unit) of its provision. According to the degree of need for medical care, those affected are distinguished:

· those in need of emergency medical care

· not in need of medical assistance at this stage (help may be delayed)

· those affected in terminal conditions, in need of symptomatic care, with an injury incompatible with life.

Evacuation sign - necessity, order of evacuation, type of transport and position of the victim in transport, evacuation purpose. Based on this sign, those affected are divided into groups:

· those subject to evacuation to other territorial, regional medical institutions or the center of the country, taking into account the evacuation purpose, priority, method of evacuation (lying or sitting), type of transport

· subject to stay in this medical institution (depending on the severity of the condition) temporarily or until the final outcome

· those subject to return to the place of residence (settlement) of the population for outpatient treatment or medical observation.

To successfully conduct medical triage, it is necessary to create proper conditions during the stages of medical evacuation. It is necessary to highlight required amount medical personnel, creating triage teams from them, equipped with appropriate instruments, devices, means of recording triage results, etc.

Medical personnel of any level of training and professional competence must first carry out selective triage: identify those affected who are dangerous to others. Then, through a quick review of those affected, identify those most in need of medical care (presence of external bleeding, asphyxia, convulsive condition, women in labor, children, etc.).

Priority remains for those in need of emergency medical care.

After the selective triage method, the triage team proceeds to sequential examination of the affected individuals. The team simultaneously examines two affected people: one has a doctor, a nurse and a receptionist, and the second has a paramedic (nurse and receptionist). The doctor, having made a triage decision on the 1st affected person, moves on to the 2nd one and receives information about it from the paramedic. Having made a decision, he moves on to the 3rd affected person, receiving information from the nurse. At this time, the paramedic examines the 4th injured person, etc. The porter unit implements the doctor’s decision in accordance with the sorting mark. With this “conveyor” method of work, one sorting team can sort up to 30-40 stretchers affected by trauma or hazardous hazardous materials (with emergency care) in an hour.

In the process of triaging all victims based on their assessment general condition, the nature of the damage and the complications that arise, taking into account the prognosis, are divided into 5 triage groups:

* Triage group I: victims with extremely severe injuries incompatible with life, as well as those in terminal state(atonal), which require only symptomatic treatment. The prognosis is unfavorable.

* Triage group II: victims with severe injuries accompanied by rapidly increasing life-threatening disorders of the main vital signs important functions organism, the elimination of which requires urgent treatment and preventive measures. The prognosis may be favorable if they receive prompt medical attention. Patients in this group need help for urgent life reasons.

* Triage group III: victims with severe and moderate injuries that do not pose an immediate threat to life, for whom assistance is provided in the 2nd priority or it can be delayed until they arrive at the next stage of medical evacuation

* IV triage group: victims with moderate injuries with mild or no functional disorders

Triage group V: victims with minor injuries requiring outpatient treatment.